Provider Demographics
NPI:1669647889
Name:SIDDIQUI, WAJID ALI (MD)
Entity Type:Individual
Prefix:
First Name:WAJID
Middle Name:ALI
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7303
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:1333 TAYLOR ST
Practice Address - Street 2:SUITE 6-F
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2923
Practice Address - Country:US
Practice Address - Phone:803-296-3273
Practice Address - Fax:803-296-7061
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT186425207R00000X
SC34048207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC340483Medicaid
SC340483Medicaid